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7121. Psn-Pdf (pdf file)
      psnet.ahrq.gov/node/41006/psn-pdf
      December 21, 2011 - Failure to notify reportable test results: significance in medical malpractice. December 21, 2011 Gale BD, Bissett-Siegel DP, Davidson SJ, et al. Failure to notify reportable test results: significance in medical malpractice. J Am Coll Radiol. 2011;8(11):776-9. doi:10.1016/j.jacr.2011.06.023. https://psnet.ahrq.go…

7122. Psn-Pdf (pdf file)
      psnet.ahrq.gov/node/46736/psn-pdf
      December 17, 2018 - Back to basics: the Universal Protocol. December 17, 2018 Spruce L. Back to Basics: The Universal Protocol: 1.4 www.aornjournal.org/content/cme. AORN J. 2018;107(1):116-125. doi:10.1002/aorn.12002. https://psnet.ahrq.gov/issue/back-basics-universal-protocol Wrong-site, wrong-procedure, and wrong-patient errors are…

7123. Psn-Pdf (pdf file)
      psnet.ahrq.gov/node/42670/psn-pdf
      January 09, 2014 - Meta-analysis of surgical safety checklist effects on teamwork, communication, morbidity, mortality, and safety. January 9, 2014 Lyons VE, Popejoy LL. Meta-analysis of surgical safety checklist effects on teamwork, communication, morbidity, mortality, and safety. West J Nurs Res. 2014;36(2):245-61. doi:10.1177/019…

7124. Psn-Pdf (pdf file)
      psnet.ahrq.gov/node/60822/psn-pdf
      August 19, 2020 - An examination of medical malpractice claims involving physician trainees. August 19, 2020 Myers LC, Gartland RM, Skillings J, et al. An examination of medical malpractice claims involving physician trainees. Acad Med. 2020;95(8):1215-1222. doi:10.1097/acm.0000000000003117. https://psnet.ahrq.gov/issue/examination…

7125. Psn-Pdf (pdf file)
      psnet.ahrq.gov/node/73631/psn-pdf
      August 25, 2021 - Patient harm from cardiovascular medications. August 25, 2021 Paradissis C, Cottrell N, Coombes ID, et al. Patient harm from cardiovascular medications. Ther Adv Drug Saf. 2021;12:204209862110274. doi:10.1177/20420986211027451. https://psnet.ahrq.gov/issue/patient-harm-cardiovascular-medications Adverse drug event…

7126. Psn-Pdf (pdf file)
      psnet.ahrq.gov/node/60980/psn-pdf
      January 01, 2022 - Analysis of risk factors for patient safety events occurring in the emergency department. October 7, 2020 Alsabri M, Boudi Z, Zoubeidi T, et al. Analysis of risk factors for patient safety events occurring in the emergency department. J Patient Saf. 2022;18(1):e124-e135. doi:10.1097/pts.0000000000000715. https://p…

7127. Psn-Pdf (pdf file)
      psnet.ahrq.gov/node/837605/psn-pdf
      June 29, 2022 - Under the Skin. The Hidden Toll of Racism on American Lives and on the Health of our Nation. June 29, 2022 Villarosa L. New York, NT: Doubleday: 2022. ISBN 9780385544887.  https://psnet.ahrq.gov/issue/under-skin-hidden-toll-racism-american-lives-and-health-our-nation Health inequities are receiving increased …

7128. Psn-Pdf (pdf file)
      psnet.ahrq.gov/node/45792/psn-pdf
      December 20, 2017 - Reevaluation of diagnosis in adults with physician- diagnosed asthma. December 20, 2017 Aaron SD, Vandemheen KL, FitzGerald M, et al. Reevaluation of Diagnosis in Adults With Physician- Diagnosed Asthma. JAMA. 2017;317(3):269-279. doi:10.1001/jama.2016.19627. https://psnet.ahrq.gov/issue/reevaluation-diagnosis-adu…

7129. Psn-Pdf (pdf file)
      psnet.ahrq.gov/node/74238/psn-pdf
      January 12, 2022 - Program access, depressive symptoms, and medical errors among resident physicians with disability. January 12, 2022 Meeks LM, Pereira-Lima K, Frank E, et al. Program access, depressive symptoms, and medical errors among resident physicians with disability. JAMA Netw Open. 2021;4(12):e2141511. doi:10.1001/jamanetwo…

7130. Psn-Pdf (pdf file)
      psnet.ahrq.gov/node/48185/psn-pdf
      August 28, 2019 - Addressing the elephant in the room: a shame resilience seminar for medical students. August 28, 2019 Bynum WE, Adams A, Edelman CE, et al. Addressing the Elephant in the Room: A Shame Resilience Seminar for Medical Students. Acad Med. 2019;94(8):1132-1136. doi:10.1097/ACM.0000000000002646. https://psnet.ahrq.gov/…

7131. Psn-Pdf (pdf file)
      psnet.ahrq.gov/node/44806/psn-pdf
      February 03, 2016 - Are Workarounds Ethical? Managing Moral Problems in Health Care Systems. February 3, 2016 Berlinger N. New York, NY: Oxford University Press; 2016. ISBN: 9780190269296. https://psnet.ahrq.gov/issue/are-workarounds-ethical-managing-moral-problems-health-care-systems Workarounds indicate process weaknesses that can …

7132. Psn-Pdf (pdf file)
      psnet.ahrq.gov/node/60263/psn-pdf
      April 22, 2020 - Rationing protective gear means checking on coronavirus patients less often. This can be deadly. April 22, 2020 Kaplan J, Presser L, Miller M. ProPublica. April 10, 2020. https://psnet.ahrq.gov/issue/rationing-protective-gear-means-checking-coronavirus-patients-less-often-can- be-deadly Increased complexity and p…

7133. Psn-Pdf (pdf file)
      psnet.ahrq.gov/node/45052/psn-pdf
      June 08, 2016 - Mean girls of the ER: the alarming nurse culture of bullying and hazing. June 8, 2016 Robbins A. Good Housekeeping. May 20, 2016. https://psnet.ahrq.gov/issue/mean-girls-er-alarming-nurse-culture-bullying-and-hazing Disruptive behaviors are receiving increased attention as a cultural factor that contributes to med…

7134. Psn-Pdf (pdf file)
      psnet.ahrq.gov/node/73498/psn-pdf
      July 14, 2021 - Leaving a discontinued FentaNYL infusion attached to the patient leads to a tragic error July 14, 2021 ISMP Medication Safety Alert! Acute care edition. 2021;26(13);1-2. https://psnet.ahrq.gov/issue/leaving-discontinued-fentanyl-infusion-attached-patient-leads-tragic-error High-alert medication misadministration i…

7135. Psn-Pdf (pdf file)
      psnet.ahrq.gov/node/850360/psn-pdf
      June 14, 2023 - Taking a closer look at medication errors that involve oxytocin. June 14, 2023 ISMP Medication Safety Alert! Acute care edition. June 1, 2023; 28(11):1-6. https://psnet.ahrq.gov/issue/taking-closer-look-medication-errors-involve-oxytocin Oxytocin, which is commonly used to induce labor, has been associated with ad…

7136. Psn-Pdf (pdf file)
      psnet.ahrq.gov/node/42036/psn-pdf
      March 18, 2013 - Changes in adverse event rates in hospitals over time: a longitudinal retrospective patient record review study. March 18, 2013 Baines RJ, Langelaan M, de Bruijne M, et al. Changes in adverse event rates in hospitals over time: a longitudinal retrospective patient record review study. BMJ Qual Saf. 2013;22(4):290-8…

7137. Psn-Pdf (pdf file)
      psnet.ahrq.gov/node/73605/psn-pdf
      August 18, 2021 - Adverse events in emergency department boarding: a systematic review. August 18, 2021 Rocha HM, Farre AGM, Santana Filho VJ. Adverse events in emergency department boarding: a systematic review. J Nurs Scholarsh. 2021;53(4):458-467. doi:10.1111/jnu.12653. https://psnet.ahrq.gov/issue/adverse-events-emergency-depar…

7138. Psn-Pdf (pdf file)
      psnet.ahrq.gov/node/38326/psn-pdf
      January 14, 2009 - Results of a medication reconciliation survey from the 2006 Society of Hospital Medicine national meeting. January 14, 2009 Clay BJ, Halasyamani L, Stucky ER, et al. Results of a medication reconciliation survey from the 2006 Society of Hospital Medicine national meeting. J Hosp Med. 2008;3(6). doi:10.1002/jhm.370.…

7139. Psn-Pdf (pdf file)
      psnet.ahrq.gov/node/848091/psn-pdf
      April 26, 2023 - The high cost of retained surgical items. April 26, 2023 Moorehead LD. Outpatient Surgery. April 5, 2023. https://psnet.ahrq.gov/issue/high-cost-retained-surgical-items Retained surgical items (RSIs) are considered “never events” but continue to be a source of patient harm. This article discusses the various facto…

7140. Psn-Pdf (pdf file)
      psnet.ahrq.gov/node/42436/psn-pdf
      August 07, 2013 - Office-based physicians are responding to incentives and assistance by adopting and using electronic health records. August 7, 2013 Hsiao C-J, Jha AK, King J, et al. Office-based physicians are responding to incentives and assistance by adopting and using electronic health records. Health Aff (Millwood). 2013;32(8…